Geographic atrophy (GA) is the advanced, non-exudative form of age-related macular degeneration (AMD), characterized by progressive atrophy of the retinal pigment epithelium, photoreceptors, and choriocapillaris. GA leads to irreversible central vision loss, and as such is an active area of research and focus in the eyecare industry.1
It is estimated that GA affects over 5 million individuals worldwide, with prevalence expected to double over the next two decades.2 Although GA progresses slowly, its impact on the fundamentals of daily living, such as reading and driving, is significant. Early detection of GA allows for timely patient education, lifestyle modifications, and potential access to emerging therapies, which may slow progression.3
While management, which includes low vision counseling, nutritional guidance, and longitudinal monitoring with advanced imaging modalities continue to be the foundation of care for GA patients, the recent FDA approvals of pegcetacoplan (SYFOVRE) and avacincaptad pegol (IZERVAY) now obligate optometrists to play a critical role in identifying candidates for treatment of GA.3
Management includes low vision counseling, nutritional guidance, and longitudinal monitoring with advanced imaging modalities.3,4
Guiding patients through their GA journey
When caring for patients with GA, it is essential for optometrists to not only provide clinical management but also to educate patients on expectations of disease course and possible outcomes.
Much like preparing a patient for cataract surgery, optometrists should establish a clear dialogue: outlining what symptoms patients may first notice, what the diagnostic process will involve, what treatment options may be discussed by the retinal specialist, and how to set realistic expectations for outcomes.
Recognizing early symptoms
Initial symptoms often include subtle changes in vision, including facial recognition, difficulty seeing in dimly lit environments, or blurred or slightly distorted vision. Patients often attribute these symptoms to normal aging, downplaying their importance, which can delay diagnosis.
For this reason, ODs should proactively inquire about these changes when suspicion of GA is noted based on exam findings, and explain the importance of noticing early symptoms of GA. Patients over 60 or those with a known history of AMD reporting these symptoms should be scheduled for prompt further evaluation.
Questions to ask if GA is suspected:5,6
- Have you noticed any blind spots, dark patches, or blurry areas in the center of your vision (for example, missing spots when looking straight ahead)?
- Do straight lines or objects ever appear wavy, bent, or distorted?
- Do you have trouble seeing in dim lighting or adjusting when moving from bright light to a darker room?
- Do you find yourself needing brighter lights for tasks such as reading?
- Are printed words or small text becoming blurry or harder to read even when wearing your glasses?
- Is it becoming difficult to read fine print or spend as much time reading as you used to?
- Has your vision affected your ability to drive, especially at night or in low-light conditions?
- Are your symptoms affecting one eye or both eyes?
- When did you first notice any changes in your vision, and how long have you been experiencing these symptoms?
- Did your vision problems come on suddenly or did they develop gradually over time?
- Are the vision changes constant, or do they come and go?
- Have you noticed your vision getting progressively worse over time?
This early symptomatic stage of GA is frequently overlooked, with subtle complaints attributed to cataracts or normal aging. This leads to missed opportunities for early counseling, lifestyle interventions, and discussions about treatment readiness.
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The Geographic Atrophy Patient Journey
This flowchart guides optometrists step-by-step through the geographic atrophy treatment process, including identifying initial symptoms, utilizing diagnostic imaging, patient education, and co-management.
Risk factors of GA
Age remains the strongest predictor of GA, and certain genetic variants such as CFH and ARMS2 further elevate risk. These and other associations should be incorporated into patient education by optometrists.
Lifestyle factors—including smoking, cardiovascular disease, and diets low in antioxidants and omega-3 fatty acids—also play significant roles. While it can be overwhelming for patients to hear about it in this way, they often respond well when risks are explained with steps that can be taken to reduce risk.
For example, smoking cessation, managing cardiovascular health with diet and exercise, and following AREDS2 supplement recommendations can all be positioned as positive, actionable strategies for supporting retinal health.7
Initial screening and diagnosis of GA
During the initial evaluation, patients should be prepared for a dilated retinal examination along with the use of advanced imaging such as those listed below.
- Optical coherence tomography (OCT) allows for precise identification of outer retinal atrophy and choroidal thinning. Using the enhanced depth imaging (EDI) feature of some OCTs can highlight early changes by increasing the resolution of the outer retina and RPE.
- Fundus autofluorescence (FAF) can identify areas of atrophy in GA with hypoautofluorescence, as well as regions of photoreceptor damage likely to progress, which correspond to hyperautofluorescence.8
- Color fundus photography, though less sensitive in early detection, remains useful for documentation and longitudinal monitoring. Overlay and side-by-side features allow for easy comparison from one visit to the next.
In order to help patients understand why multiple and often repeated tests are necessary, optometrists should also explain that part of the management of GA includes ruling out other potential mimickers, such as those noted below:
- Dry AMD without atrophy
- Neovascular (wet) AMD
- Myopic degeneration
- Stargardt disease
- Inherited parafoveal atrophies
- Medication-related retinal toxicity
Patient education and expectations
Once GA is confirmed, patients benefit from a structured explanation of the disease course. Patients should be made aware that atrophy progression varies among individuals, but that studies indicate that GA can extend from non-central to central vision in as little as 1.5 years.
They should also understand that while GA is progressive, treatments such as intravitreal injections of SYFOVRE or IZERVAY may help slow its progression. In addition, patients should be counseled on the role of lifestyle choices, including smoking cessation, UV protection, and adherence to AREDS2 nutritional guidelines.7
Sample patient conversation
"In the back of your eye, you have a layer of cells that help you see clearly, especially when you’re reading, driving, or recognizing faces. Today, we notice that you have signs of a condition known as geographic atrophy, in which those cells slowly wear away, creating areas where your vision isn’t as sharp.
You may notice things like missing letters when you read, trouble adjusting from bright light to dim rooms, or a blurry or dark spot in your central vision. We notice early changes today; however, this is a condition that gradually progresses.
It’s easy to confuse the subtle symptoms with other things, such as cataracts or just a feeling or normal aging changes. But it’s important that we identify it early so we can take steps to protect as much of your vision as possible for as long as we can."
Management of geographic atrophy
Ongoing management requires both medical treatment and supportive care. Current therapies, including pegcetacoplan and avacincaptad pegol, have been shown to slow GA progression by 17 to 22% in pivotal trials.4
These drugs are both inhibitors of the complement system, blocking inflammatory pathways linked to GA. Patients should be counseled that while these treatments do not restore lost vision, they may help preserve central vision for a longer period of time.
Setting realistic expectations is vital; patients should understand that peripheral vision is typically preserved and that complement inhibitors like SYFOVRE and IZERVAY are designed to slow the disease rather than stop it completely. Reinforcing that the goal is to maintain independence and quality of life can help patients stay motivated and compliant with care.
Sample patient conversation
"There are new treatments available that have been shown to slow down the progression of geographic atrophy. These treatments are provided by a retinal specialist and involve small injections into the eye.
While these injections don’t restore vision that has already been lost, studies show they can help slow the disease, preserving your central vision longer. Depending on your exam and the retinal specialist’s evaluation, you may be a candidate for these treatments. There are also clinical trials available in some cases that are testing new options.
Along with these medical treatments, things like wearing sunglasses for UV protection, eating a diet rich in nutrients, and not smoking can also support your eye health. We’ll work together to make sure you’re doing everything possible to protect your sight."
Don't forget to download The Geographic Atrophy Patient Journey Flowchart!
Ready the patient for referral
Referral to a retinal specialist is a key point in the GA care pathway. Optometrists should explain that the referral is not a sign of “bad news,” but rather a proactive step to evaluate treatment options. A referral may be needed to confirm the diagnosis, assess eligibility for intravitreal therapies, or monitor rapid progression.
Prepare the patient for discussions with the retinal specialist, who will review treatment eligibility and scheduling. If functional vision loss becomes significant, referral for low vision rehabilitation services may also be appropriate. Furthermore, early referral for low vision is critical for the best visual outcome, allowing patients with best corrected vision of 20/30 or worse to transition early in the phases of vision loss ahead.
Tips for co-management success
Once a patient with GA has been referred to a retinal specialist, strong co-management habits can contribute to a positive patient experience and ensure the patient will receive optimal care.
The referring optometrist should:
- Provide clear documentation of the GA area and progression at the time of referral and at any follow-up visits.
- Continue with regular imaging as indicated (e.g., every 3 to 6 months), based on the imaging conducted by the retinal specialist.
- Ongoing communication with the retinal specialist, which clearly delineates roles and expectations. For example, if the retinal specialist will repeat the OCT in 3 months, the optometrist may not need to also perform OCT.
- Schedule a follow-up appointment with the optometrist for the comprehensive eye exam, as indicated by the retina specialist.
- Most retinal specialists will only conduct retinal exams, so ensuring the patient understands the importance of regular optometric visits alongside the specialty retinal visits is critical for the remaining eye health and visual function (e.g., intraocular pressure, refraction).
Communicating to the patient that you, as their optometrist, will continue to be involved in their care helps maintain trust and ensures the patient feels they are being cared for by a coordinated team.
Sample patient script
"One of the most important parts of caring for geographic atrophy is regular follow-up. Even if you’re feeling like your vision hasn’t changed much, we know from research that GA can sometimes progress quickly—from being outside your central vision to affecting it in just over a year.
That’s why we’ll want to see you every few months for specialized scans of your retina. These visits help us track any changes and make sure you’re getting the right care at the right time. If you’re receiving treatment, follow-ups also allow us to see how well the therapy is working and adjust if needed.
Staying on top of these visits gives you the best chance of maintaining your independence and quality of life. We will coordinate with your retinal specialist to be sure you are getting what you need, and that you aren’t receiving any unnecessary duplicate care."
Common missteps in GA management
Having a roadmap for GA management provides a structured, stepwise process to ensure no critical stage is missed, facilitating systematic imaging, education, and referral protocols in daily practice.
Common missteps in GA management include:
- Delaying OCT and FAF imaging when subtle (or no) symptoms arise. These imaging modalities can assist in early detection.
- Failing to educate patients early on GA progression and lifestyle interventions. Smoking cessation, cardiovascular health, and nutritional supplementation remain standards of care in GA management.
- Not referring promptly when treatments become available. It is the optometrist's medical and ethical responsibility to educate patients about new treatments.
- Overlooking or delaying low vision rehabilitation. Early referral can help with functional improvements and also the mental acceptance of the need for assistance.
5 key takeaways for GA management
- Early detection and monitoring are critical for patient outcomes and potential access to new treatments.
- Patient education creates an opportunity for patient engagement and improves adherence to monitoring and lifestyle recommendations.
- High-quality imaging (OCT and FAF) is indispensable in detecting and monitoring GA progression.
- Optometrists are important in GA care, with evolving roles in diagnosis, treatment counseling, and co-management with retina specialists.
- Co-management improves efficiency and patient satisfaction, ensuring timely care and minimizing unnecessary referrals
In closing
By providing a step-by-step framework, optometrists can guide patients with GA through their journey in a way that is both informative and reassuring.
From identifying early symptoms and risk factors to coordinating referrals and supporting treatment adherence, ODs play a central role in helping patients understand their condition and stay engaged in their care.
A structured, empathetic dialogue—much like the counseling provided for cataract surgery—can make a significant difference in how patients experience and manage geographic atrophy.
